Inquest into death of 83 year old man finds mistake by Southampton General Hospital junior doctor led to stroke

Posted on: 1st October 2015

Grahame Short, the Coroner at the inquest into the death of Frank Locke, an 83-year-old retired photographer and father of four from Bournemouth, has found that ‘on the balance of probability’ a mistake by a junior doctor, made whilst Mr Locke was recovering from a successful heart operation, led to his subsequent stroke.

The stroke reduced his ability to swallow and Mr Locke went on to lose a considerable amount of weight, making it harder for him to recover from his operations and fight infection. He died from pneumonia on 13 January this year at Royal Bournemouth Hospital.

The inquest, held at Winchester Coroner’s Court last week and concluded today, heard how in early September 2014, Mr Locke underwent heart surgery at Southampton General Hospital. The surgery was successful but Mr Locke subsequently developed abdominal pains and required bowel surgery. On 19 September, whilst recovering from the operations, Mr Locke had a new tube inserted into his neck by a junior doctor for the administering of infusions. The doctor had never carried out the procedure before and undertook it incorrectly. Mr Locke was wrongly infused into his artery rather than a vein.

The senior doctor supervising was called away before relevant checks were made, so the mistake was not picked up by him. Further blood tests that would have alerted staff to the problem were also not undertaken. Later that day Mr Locke had a stroke which left him with limited mobility in his left side. He was then admitted to intensive care.

In early October Mr Locke was transferred to Royal Bournemouth Hospital. The inquest heard how his health then started to go downhill and his food intake became very limited because the stroke had affected his ability to swallow. During his stay at the hospital he developed numerous infections and on 13 January 2015, he died.

The Coroner gave a narrative verdict, concluding that:

‘Frank Locke suffered from ischaemic heart disease which necessitated cardiac surgery conducted at Southampton General Hospital on 8 September 2014. The surgery was carried out appropriately but he required a colectomy on 11 September due to the complications of the initial operation. Frank Locke suffered a stroke likely to be the result of the misplaced CVC line which reduced his ability to swallow and his ability to mobilise. Both of these factors contributed to a reduction in his weight and his body’s capacity to recover from the operations and cope with infections. His post operation nutritional intake was inadequate and his weight declined significantly before it stabilised.’

The Coroner highlighted that the ‘critical factors’ in Mr Locke’s death were that the junior doctor who was carrying out the procedure for the first time had not read the relevant policy document and that the senior doctor supervising him was called away to another patient before the relevant checks were made. Whilst he criticised poor communication between the two hospitals and acknowledged delays in Bournemouth Hospital recognising Mr Locke’s weight drop and taking practical steps to stabilise it, he concluded that this would have not been so critical had Mr Locke not had the stroke which affected his ability to swallow.

Mr Locke’s partner, Barbara Dawkins says: “Frank had a very positive attitude to life and fought hard to stay fit and healthy. He refused to let illness get the better of him. He had reservations about going in for heart surgery but decided to go ahead with it as he hoped it would give him a better quality of life. His surgery was successful so it is devastating to hear that a mistake in the treatment he received at Southampton General Hospital led to his stroke and to him becoming so gravely ill. If Frank had been able to eat and get the nutrition he needed to keep him strong, I have no doubt he would have been better able to fight off the infections that eventually ended his life.”

Nina Ali, medical negligence lawyer at Hodge Jones & Allen represented Barbara Dawkins. She says: “The Coroner’s investigation has established that the mistake made with the insertion of the line into Mr Locke’s neck following his operation was most likely the cause of his subsequent stroke. The procedure was carried out by a junior doctor who was not properly supervised and was not aware of the hospital’s policy on line insertion. This raises questions about the supervision and training of doctors at the hospital and is something I would call upon Southampton General Hospital to address immediately.”